Conversion Disorder
DSM-III Diagnostic Criteria A'''. The predominant disturbance is a loss of or alteration in physical functioning suggesting a physical disorder. '''B. Psychological factors are judged to be etiologically involved in the symptom, as evidenced by one of the following: # there is a temporal relationship between an environmental stimulus that is apparently related to a psychological conflict or need and the initiation or exacerbation of the symptom # the symptom enables the individual to avoid some activity that is noxious to him or her # the symptom enables the individual to get support from the environment that otherwise might not be forthcoming C'. It has been determined that the symptom is ''not under voluntary control. '''D. The symptom cannot, after appropriate investigation, be explained by a known physical disorder or pathological mechanism. E'''. The symptom is not limited to pain or to a disturbance in sexual functioning. '''F. Not due to Somatization Disorder or Schizophrenia. Differential Diagnosis Physical disorders Some physical disorders that present with vague, multiple, somatic symptoms, such as multiple sclerosis or systemic lupus erythematosis, may early in their course be misdiagnosed as conversion symptoms. A diagnosis of Conversion Disorder is suggest if if the symptoms are inconsistent with the actual known physical disorder - for example, motor signs of good function in a supposedly paralyzed part, or complaints obviously inconsistent with the anatomic distribution of the nervous system. Another example would be "anesthesia" of the hand conforming to the concept of the hand rather than to the functional area served by a specific part of the nervous system. In another example, an individual with conversion blindness may be found to have normal pupillary responses and evoked potentials as measured by an EEG. Resolution of symptoms through suggestion, hypnosis, or narcoanalysis suggests a conversion symptom. Temporary improvement due to suggestion has little diagnostic value since this may also occur with true physical illness. In undiagnosed physical disorder physical symptoms are present that are not explained by a known physical disorder, but there is no evidence that the symptom serves a psychological purpose. Physical disorders in which psychological factors often play an important role, such as irritable colon or bronchial asthma, should not be diagnosed as Conversion Disorders, since demonstrable organic pathology or a pathophysiological mechanism that accounts for the disorder is present. Somatization Disorder and Schizophrenia Somatization Disorder and, more rarely, Schizophrenia may have conversion symptoms. However, the diagnosis of Conversion Disorder should not be made when such symptoms are due to either of these more pervasive disorders. Psychosexual Dysfunctions For many of the Psychosexual Dysfunctions, it is difficult to determine whether the symptom, such as impotence in the male or lack of sexual excitement in the female, represents a physiological reaction to anxiety or a direct expression of a psychological conflict or need (conversion symptom). For this reason, and in order to group all of the sexual disturbances together, conversion symptoms involving sexual dysfunction are not diagnosed as Conversion Disorder, but rather as Psychosexual Dysfunction. Psychogenic Pain Disorder Some psychogenic pain can be conceptualized as a conversion symptom; but because of the different course and treatment implications, all such cases should be diagnosed as Psychogenic Pain Disorder. Hypochrondriasis In Hypochondriasis typically there are physical symptoms, but there is no actual loss or distortion of bodily function. Factitious Disorder In Factitious Disorder with Physical Symptoms, the symptoms are, by definition, under voluntary control; and the simulated illness rarely takes the form of neurological symptoms that are likely to be confused with conversion symptoms. However, distinguishing conversion seizures from seizures as a manifestation of Factitious Disorder is often extremely difficult. Malingering In Malingering the symptom production is under the individual's voluntary control and is in pursuit of a goal that is obviously recognizable given the individual's environment circumstance; this goal frequently involves the prospect of material reward or the avoidance of unpleasant work or duty. DSM-IV Diagnostic Criteria A'''. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. '''B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. C'''. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering). '''D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E'''. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. '''F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder. Specify type of symptom or deficit: * With Motor Symptom or Deficit * With Sensory Symptom or Deficit * With Seizures or Convulsions * With Mixed Presentation Subtypes The following subtypes are noted based on the nature of the presenting symptom or deficit: With Motor Symptom or Deficit This subtype includes such symptom as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or "lump in throat," aphonia, and urinary retention. With Sensory Symptom or Deficit This subtype includes such symptoms as loss of touch or pain sensation, double vision, blindness, deafness, and hallucinations. With Seizures or Convulsions This subtype includes seizures or convulsions with voluntary motor or sensory components. With Mixed Presentation This subtype is used if symptoms of more than one category are evident. Differential Diagnosis General medical conditions and substance-induced etiologies The major diagnostic concern in evaluating potential conversion symptoms is the exclusion of occult neurological or other general medical conditions and substance (including medication)-induced etiologies. Appropriate evaluation of potential general medical conditions (e.g., multiple sclerosis, myasthenia gravis) should include careful review of the current presentation, the overall medical history, neurological and general physical examinations, and appropriate laboratory studies, including investigation for use of alcohol and other substances. Other mental disorders Pain Disorder or a Sexual Dysfunction is diagnosed instead of Conversion Disorder if the symptoms are limited to pain or to sexual dysfunction, respectively. An additional diagnosis of Conversion Disorder should not be made if conversion symptoms occur exclusively during the course of Somatization Disorder. Conversion Disorder is not diagnosed if symptoms are better accounted for by another mental disorder (e.g., catatonic symptoms or somatic delusions in Schizophrenia or other Psychotic Disorders or Mood Disorder or difficulty swallowing during a Panic Attack). In Hypochondriasis, the individual is preoccupied with the "serious disease" underlying the pseudoneurological symptoms, whereas in Conversion Disorder the focus is on the presenting symptom and there may be la belle indifference. In Body Dysmorphic Disorder, the emphasis is on a preoccupation with an imagined or slight defect in appearance, rather than a change in voluntary motor or sensory function. Conversion Disorder shares features with Dissociative Disorders. Both disorders involve symptoms that suggest neurological dysfunction and may also have shared antecedents. If both conversion and dissociative symptoms occur in the same individual (which is common), both diagnoses should be made. Psychotic Disorders It is controversial whether hallucinations ("pseudohallucinations") can be considered as the presenting symptom of Conversion Disorder. As distinguished from hallucinations that occur in the context of a Psychotic Disorder (e.g., Schizophrenia or another Psychotic Disorder, a Psychotic Disorder Due to a General Medical Condition, a Substance-Related Disorder, or a Mood Disorder With Psychotic Features), hallucinations in Conversion Disorder generally occur with intact insight in the absence of other psychotic symptoms, often involve more than one sensory modality (e.g., a hallucination involving visual, auditory, and tactile components), and often have a naive, fantastic, or childish content. They are often psychologically meaningful and tend to be described by the individual as an interesting story. Factitious Disorders and Malingering Symptoms of Factitious Disorders and Malingering are intentionally produced or feigned. In Factitious Disorder, the motivation is to assume the sick role and to obtain medical evaluation and treatment, whereas more obvious goals such as financial compensation, avoidance of duty, evasion of criminal prosecution, or obtaining drugs are apparent in Malingering. Such goals may resemble "secondary gain" in conversion symptoms, with the distinguishing feature of conversion symptoms being the lack of conscious intent in the production of the symptom. DSM-5 Diagnostic Criteria A'''. One or more symptoms of altered voluntary motor or sensory function. '''B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. C'''. The symptom or deficit is not better explained by another medical or mental disorder. '''D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Specify symptom type: * With weakness or paralysis * With abnormal movement (e.g., tremor, dystonic movement, myoclonus, gait disorder) * With swallowing symptoms * With speech symptom '''(e.g., dysphonia, slurred speech) * '''With attacks or seizures * With anesthesia or sensory loss * With special sensory symptom '''(e.g., visual, olfactory, or hearing disturbance) * '''With mixed symptoms Specify if: * Acute episode: Symptoms present for less than 6 months. * Persistent: Symptoms occurring for 6 months or more. Specify if: * With psychological stressor (specify stressor) * Without psychological stressor Differential Diagnosis If another mental disorder better explains the symptoms, that diagnosis should be made. However the diagnosis of conversion disorder may be made in the presence of another mental disorder. Neurological disease The main differential diagnosis is neurological disease that might better explain the symptoms. After a thorough neurological assessment, an unexpected neurological disease cause for the symptoms is rarely found at follow up. However, reassessment may be required if the symptoms appear to be progressive. Conversion disorder may coexist with neurological disease. Somatic symptom disorder Conversion disorder may be diagnosed in addition to somatic symptom disorder. Most of the somatic symptoms encountered in somatic symptom disorder cannot be demonstrated to be clearly incompatible with pathophysiology (e.g., pain, fatigue), whereas in conversion disorder, such incompatibility is required for the diagnosis. The excessive thoughts, feelings, and behaviors characterizing somatic symptom disorder are often absent in conversion disorder. Factitious disorder and malingering The diagnosis of converstion disorder does not require the judgement the the symptoms are not intentionally produced (i.e., not feigned), because assessment of conscious intention is unreliable. However, definite evidence of feigning (e.g., clear evidence that loss of function is present during the examination but not at home) would suggest a diagnosis of factitious disorder if the individual's apparent aim is to assume the sick role or malingering if the aim is to obtain an incentive such as money. Dissociative disorders Dissociative symptoms are common in individuals with conversion disorder. If both conversion disorder and a dissociative disorder are present, both diagnoses should be made. Body dysmorphic disorder Individuals with body dysmorphic disorder are excessively concerned about a perceived defect in their physical features but do not complain of symptoms of sensory of motor functioning in the affected body part. Depressive disorders In depressive disorders, individuals may report general heaviness of their limbs, whereas the weakness of conversion disorder is more focal and prominent. Depressive disorders are also differentiated by the presence of core depressive symptoms. Panic disorder Episodic neurological symptoms (e.g., tremors and paresthesias) can occur in both conversion disorder and panic attacks. In panic attacks, the neurological symptoms are typically transient and acutely episodic with characteristic cardiorespiratory symptoms. Loss of awareness with amnesia for the attack and violent limb movements occur in non-epileptic attacks, but not in panic attacks.